Plantar pressures under the foot of 106 rheumatoid feet were measured with the cooperation of affiliated hospitals. The methods used were by pedograph using foot print apparatus and measurement of plantar pressure with a transducer. 1. The types of foot impressions using foot prints were larger in the order of normal type, varus type, hind-foot type, valgus type, fore-foot type, dragging foot type and non-toes type. 2. In measurement of plantar pressure using transducer, the number of varus type was the largest from the form of recorded curve, followed by the normal type, and the others were in the same sequence as 1. The largest articular damage roentgenologically was found in the hind foot type and varus type. 3. Plantar pressure ratios to the body weight was as follows: pressure under the forefoot was very low in A group, pressure under the heel was very low in B group. Plantar pressures of the C group were closer to the control than the other 2 groups.
The results of the clinical observations of nine patients of Vitamin D resistant rickets and four patients of Vitamin D resistant osteomalacia were presented. The longest length of follow up of Vitamin D resistant rickets at Kyushu University was ten years. Treatment with a high dosage of Vitamin D was begun between 11/2 and 7 years of age. The dose of Vitamin D required for the treatment of rickets varied widely depending on the severity of the process and the age of the patient. The range necessary for adequate treatment varied 100, 000 to 400, 000 IU per day or more. Two patients showed hypercalcemia and other manifestations of Vitamin D intoxication. Three patients with deformity required osteotomy or other operation. In other patients deformities have improved with medical treatment alone. The clinical and radiological features of four patients of Vitamin D resistant osteomalacia first diagnosed in adult-hood were also described. Dwarfism and severe deformity of the legs were characteristic features. The loss of stature were resulted almost from shortness of the legs. Radiographic features were Looser zones, coarse trabecular pattern, increased bone density and ligamentous calcifications. These patients presented several difficult orthopaedic problems.
Uehlinger's disease is rare, systemic bone disease which is characterized by hyperostosis, pachydermia and clubbing finger. Since Uehlinger reported the disease as hyperostosis generalisata with pachydermia in 1941, it has been reported in various name such as Familiäre acromegalie-ähnliche Erkrankung des Skelettes (Oehme 1919), Megalia ossium et cutis (Grönberg 1927), Cutis verticis gyrata-Acromegalie-Osteoperiostitis hyperplastica (Renander), Pachydermoperiostosis (Schwarby 1962). The first case is 23 years man, who suffered from pain and hydrops of bilateral knees since 19 years. The second case is 22 years man whose chief complaint is the deformity of fingers. These two cases showed typical pachydermia on the front, clubbing finger and hyperostosis on the diaphysis without any particular findings on laboratory examination. The third case is 45 years man with polyarthralgia. This is a little atypical, because he shows neither pachydermia nor periosteal thickening in the diaphysis. These cases have no abnormality in cardio-vascular, pulmonary or gastrointestinal system. Differential diagnosis and nomenclature was discussed.
There are many surgical procedures in elephantiasis, which is caused by the disturbance of lymphatic vessel. Recently four procedures are used in the surgical management of lymphedema. They are the Charles procedure, the omental transposition, the buried dermal flap, and subcutaneous excision of the lymphedematous tissue beneath skin flaps. Now we report the result which operated by the fourth surgical procedure.
A fifteen year old boy with characteristic findings of von Recklinghausen's disease admitted to our clinic due to malunited fracture of the right forearm. In July, 1970, osteosynthesis was performed, but two months after surgery, he fell down and refracture occurred. Roentgenogram revealed irregularity of the shaft of the bones, narrowing of bone diameter, and erosive defects which were characteristic to von Recklinghausen's disease. Neurofibroma was not demonstrated histologically from the neighbouring tissue, but fibrous tissue was found to be filled.
To clarify the biochemical characteristics of nerve tumors, we studied esterase isozymes in the extracts of normal nerve tissue, neurinomas, neurofibromatosis and neurogenic sarcomas. Esterase isozymes were separated on polyacrylamide gel and were stained by the simultaneous azo dye coupling method as previously described. Normal nerve tissue, neurinomas and neurofibromatosis could be recognized and distinguished by means of their specific isozyme patterns. However isozyme pattern of neurogenic sarcoma showed some resemblances to that of neurinoma, esterase activity in band F of neurogenic sarcoma seemed to be much higher than that of neurinoma. Our preliminary data suggest the possibility of chemical diagnosis of nerve tumors.
A boy aged 9 admitted to our clinic on July 1975, complaining of pain and swelling in the right scapular region. Roentgenograms showed a round osteolytic defect, about two centimeters in diameter in the right scapula. The area of bone destruction was filled with yellowish tissue, which was easily curetted from the bone. The histological picture revealed a granulomatous lesion with widely scattered histiocytic cells, and with foci of eosinophilic infiltration. Culture of the tissue did not given bacterial growth. By roentgenograms, the defect showed definite healing sixteen months after curettage.
We have reported a case of giant cell tumor in the metacarpal bone previously, finding the giant cell tumor of short tubular bone is very rare. We have recently experienced another case of giant cell tumor which occured in the first metacarpal bone of a young man. He was 17 years old, and was complaining of pain and swelling in the left metacarpal portion. Roentgenogram revealed the significant destructive lesion in the metacarpal bone. 8 months after primary curettage and bone grafting, recurrence had occured. Curretage of the bony lesion and bone grafting was carried out for the recurrent bone tumor. Histologically, no evidence of malignancy was found.
Three patients with myeloma who were not suspected as having such a disease just at admission, were treated in our clinic for this few years. A 52-year-old-man with paraplegia and cachexia, was revealed as a Diffuse-Myeloma with Epidural-Myeloma by autopsy. Another 64-year-old-man with osteolytic shadow in his left femur, was histologically suspected as a reticulum-cell-sarcoma, but electron microscope showed him as a myeloma. Another 22-year-old-man with soft-part-tumor in his left thigh, was histologically vertified as an Extramedullary-Myeloma. One of the most important things on the diagnosis of a myeloma is to remember always such a disease existing in many patients.
Two cases of the spinocranial type of meningioma of the foramen magnum are prese nted. One case is 39-year-old man and another case is 34-year-old woman. Myelography is of prime importance in confirming the diagnosis and when performed with care and understanding of the anatomy without fearing of losing the Myodil into the basal cistern.
Ependymomas are not frequent in the spinal cord. Although they may arise at every level, most arise in the filum terminale at the level of the cauda equina. T. Y., a thirty-three-year-old male, was admitted to our clinic with chief complaint of sensory disturbance and weakness of the extremities. A myelogram showed a block at the level from C-1 to T-3. On July 22 1976, a laminectomy was done from C-2 to C-7, with partial removal of an intramedullary tumor. Pathological diagnosis of the tumor was cellular ependymoma.
We have reported two cases of neurinoma (intradural extramedullary tumor, dubbell tumor) in the upper cervical region. In these cases there was recovery from motor difficulty and sensory disturbance after total removal of the tumor by cervical laminectomy. Case 1. a 45-years old male had had progressige difficulty in walking for the last ten months prior to his admission to our clinic. Myelography showed incomplete block at the level of C1 and C2. Case 2. a 47-years old male had had progressive difficulty in mobility of four limbs, especially left side, for the last three months prior to his admission to our clinic. Myelography showed incomplete block at the level of C1. Patients with suboccipital headache who manifest pyramydial deficites and capricious sensory symptoms may well have a tumor of foraman magnum.
We reported 5 cases of cervical osteochondrosis with muscle atrophy, particularly in the shoulder girdle. Muscle atrophy was almostly localized at C5 & C6 myotomes, but in myelopathy case, muscle atrophy was also seen at more caudal myotomes. Sensory disturbance was seen in 4 cases, but lightened in degree compaired with muscle atrophy. In 1 case (radiculopathy), sensory disturbance was absent. Biceps tendon reflex was diminished in all cases. In a case (myelopathy), knee jerk was accelerated, but pathological reflex was absent. On X-ray findings, spondylotic changes were seen in all cases predominant at the level of C4-5, C5-6 intervertebral discs. Myelogram revealed partial and/or complete block at the level of C4-5, C5-6 intervertebral discs. We suggested that the level of the lesion was in C4-5 & C5-6 from the view point of neurological and X-ray findings.
1) Sixty-one patients received anterior operation of the cervical spines were studied roentgenographically. The duration of follow-up was from one to six years. The ages of the patients ranged from thirteen to sixty-seven years. Forty were males and twenty one were females. 2) Nineteen (31.1%) of sixty-one patients had roentgenographic changes after anterior fusion. Thirteen (21.8%) had spur formation, which was mostly seen in the cases being operated on at a single level. Eight (13.1%) had disc degeneration, mostly seen in the cases in which two or more levels were fused. Only one had instability of disc space. 3) In the cases in which the follow-up study had been made more than four years after surgery, spur formation and disc degeneration were found frequently. There were significant changes in young patients than old ones. 4) Hypermobility of adjucent cervical spines after fusion was showed frequently in cases in which two or more disc spaces were fused.
We have presented three cases with atlanto-axial dislocation due to os odontoideum, non-union of odontoid fracture and rheumatoid arthritis. They all had developed cervical myelopathy. Treating these patients, we have, as the first choice, tried to reduce the dislocation appling halo-cast traction, however complete reduction was failed in two cases. Anterior fusion of the atlanto-axial joints was performed in all of the three cases through transoral approach. One case had decompressive laminectomy prior to the anterior fusion. All three patients showed good recovery after the surgery.
Three cases of cervical spondylosis associated with tumor, which made a diagnosis difficult, were reported: Case 1. 45-year-old male. A intradural, extramedullar schwannoma of the spinal cord was found by operation. Case 2. 52-year-old female. Cranio-spinal meningioma was found at autopsy. Case 3. 59-year-old male. A metastatic lung cancer of Pancoast's type to the lower cervical spines was found by clinical examination.
Prolonged extradural block was applied for 33 patients, who were suffering from disorders of the cervical spine and had showed no improvement of their symptoms in spite of the conservative treatments. The injection was made from one to ten times, and 3.6 in average. Radicular pains were much reduced by the injection, but myelopathy that was found in some of those cases was not relieved at all. Besides, two cases with shoulder hand syndromes had complete relief after three or five injections.
A report is made in 6 cases of thoracic spondylotic myelopathy. Their age ranges from 28 years to 68 years old. Of them two cases are male and 4 are female. Generally the site of this disease is said to be most frequent at the lower thoracic vertebra, but this myelopathy can be also observed in the upper thoracic vertebra. As for the clinical symptoms sensory disturbances of the legs, disturbances of movement, and rectovesical disturbances can be pointed out, that gradually progress in some cases, while in others this myelopathy is induced by sternomutator or by fall, that aggravates by degree. X-ray picture reveal the narrowing of the inervertebral disc space, the calcification of inervetebral disc and sclerosis of the posterior margin of vertebral body in some cases, but these changes seem to be aging phenomena, that cannot at once be concsidered necessarily as the direct cause of myelopathy. There are cases where no abnomality of humoral findings, that symptoms are not always consistent. At the present stage myeography is most useful for the diagnosis. As long as the case be definititly diagnosed as myelopathy due to the disturbance of intervertebral disc, anterior decompression proves to be most rational, but there are cases difficult of diagnosis. We have performed laminectomy in five cases and obtained favorable results in all of them.
Recently, much attention has been paid to thoracic spondylotic myelopathy. One of the local factors which produce spondylotic changes could be the movability of the thoracic spine. Dynamic studies on 100 normal persons, equally chosen from a group of persons age 10 to 70 showed that movability of flexion-extension is the minimum at the level of sixth to seventh thoracic spine and becomes larger as the level goes up to cephalad or down to caudal direction. The level of eleventh to twelveth thoracic spine has greatest movability in both flexion-extension and lateral bendings and is up to three to five times more movable than the level in which the movability is smallest.
Endochondral bone formation is one of the characteristic features of the primary spongiosa. Using the metaphysis of the long bone of two-week-old normal Wistar rat, we observed three-dimensional ultrastructures of collagen fibers between the calcified cartilage matrix and osteoblasts under the field emission scanning electron microscope. Approaching the diaphysis, the bundles of collagen fibers which osteoblasts lay down on the calcified cartilage matrix increased in width. Cytoplasmic processes of osteoblasts extended between collagen fibers, which were relatively distinctly bordered by the calcified cartilage matrix, and their direction was nearly parallel to the axis of the calcified cartilage matrix.
So-called pseudarthrosis of the tibia is one of rare diseases. Only 26 cases were seen in our clinic during 50 years (1926-1976), and they were all uni-lateral cases. The following case is reported because it demonstrates both congenital bowing of the bilateral legs. A Case Report A boy aged 14 months was admitted with remarkable bending of the bilatelal tibiae and skin pigmentation. These findings were recognized immediately after the birth. Operation Left; Extirpation of the thickened periosteum Right; Extirpation of the thickened periosteum and by-pass bone graft (tibia of his father) Findings at the openation Periosteum was remarkably thickened. This is found in all of our uni-lareral cases, to which might relate the etiology of congenital pseudarthroses of the tibia.
We experienced a new born baby with very rare foot deformity, so called congenital diastasis of tibio-fibular mortise. First we tried manual correction of the diastasis and reduction of the subluxated talus. And we tried operative correction at his 7 months age, lengthened achilles tendon, released posterior capsule and corrected the diastasis by a screw. Diastasis was well corrected but slight equinus deformity remained.
The most serious deformity that can develop in the lower limb in cerebral palsy is dislocation of the hip. In the early stages of development of subluxation, in our 25 hips, both iliopsoas and adductor release are sufficient to prevent the progress of subluxation towards dislocation. In older children of them, over the age of five years, we have found no further deterioration, but in 5 of 14 hips no cnange of view radiologically after release of iliopsoas and adductor. On the other hand, in 7 of 38 hips, we could not prevent the progress of subluxation, when released the adductor only.
By questionaires the footedness would be defined to be the dominant side when one hops and stands on one foot for a long time. On fifty normal adults the relation between footedness and floor reaction by the force plate while walking was studied, and significant differences were noticed between the dominant side and the other side.
We previously reported seventeen cases in which the operation was done for the supraspinatus syndrome during the past five years and concluded that surgical treatment was very succesful and recommendable for the supraspinatus syndrome. On the other hand, thirty-one patients were treated conservatively durirng this period for the supraspinatus syndrome. Conservative treatment gave a satisfctory result in 86 per cent of the twenty-eight shoulders that could be followed up. Most patients with ex-cellenent or good results were spontenously recovered within five weeks from the first medical examination in our hospital. When there is no or silight response to conservative treatment for five to six weeks, surgery will be recommended.
Congenital clasped thumb is characterized by a tightly flexed and adducted thumb. This condition is the result of imbalance from various causes, that is, the weakness or absence of extensor muscles and tendons, the result of arthrogryposis, the complication of the hypoplastic thumb, or others. We experienced a rare case of bilateral congenital flexion-adduction deformity of the thumb. The extensor muscles and tendons were neither weak nor absent, and the thumbs were passively abducted and extended. But the extensor pollicis brevis tendon was adhesive to the glididing floor. This is a report of the findings and the surgical management.
We reported on three cases of replantation of the amputated fingers, to which we applied useful methods to anastomose in good condition, out of 11 cases which we experienced. In the first case of the avulsed thumb, we combined the neurovascular island pedicle method. In the second case, in which postoperative arterial thrombus occured, only a vascular pedicle was transferred and reanastomosed. In the third case, massive vascular defect was complicated, and Y-shaped vein grafts were applied to anastomose two proximal arteries to four peripheral arteries. We emphasized that it was important to apply other useful operative techniques to replantation of the amputated fingers.
The angiography of the iliofemoral area was disscussed and classified in 4 types concidering the anatomy of the superficial circumflex iliac artery and superficial inferior epigastric artery. 8 cases of the free hypogastric skin flap operation were tried. One of 8 cases was operated for requiring the good gliding floor of the flexor tendon. The free muscle graft operation was succeeded in 59 years old man in March, 1976. The usefulness of the omentum graft in orthopaedic was emphasized.
The author has attempted the free vascular pedicle bone graft of the long bone, the rib, to the femur, experimenting of 30 dogs, using microvascular anastomoses. Subsequently, the free vascular pedicle bone grafts have the advantages of early bone union and preserving the bone's viability, and they can be transplanted to a distant recipient site using microvascular anastomoses. As a result of the success of this experimental investigation, the author has studied the vascular anatomy of the grafted bones, fibula, rib and ileum, disecting the limbs of the cadavers and the author would like to recommend the clinical application of the free vascular pedicle bone graft.
The total of cases replanted for amputation of the limbs and fingers between December 1974 to October 1976 numbers 47. The age of the patients ranged from 2 to 64, those of high age were quite numerous. Injuries due to electric power saw were most numerous. The success rate of reattachment in the limb and hand was 100% and in the finger it was 84.0%. I report successful replantational cases and describe replantation-techniques, for example, technique of suture of digital vessels, the postoperative control, indication and function of limbs and fingers.